Client Implementation Request Form

The following information is required to create a new hire record for your organization. This information is handled with HIPAA Compliance. Please do not print this form and attempt to hand-write the information in. Your signature will be captured electronically at the end of this form and you will receive a confirmation email upon submission. Thank you.

Today's Date

AM/PM Option

Legal Company Name

DBA (If Applicable)

Main Hiring Contact Name

First NameLast Name

Main Accounting Contact Name

First NameLast Name

Main Hiring Contact Email Address

Your personal email address, not work, is suggested for privacy.

Main Accounting Contact Email Address

Your personal email address, not work, is suggested for privacy.

Main Hiring Contact Phone

Country CodeArea CodePhone Number

Main Accounting Contact Phone

Country CodeArea CodePhone Number

Email Address for Invoicing:*

example@example.com

Will the client be offering leave to the employees:*

YesNo

Paid Time Off

	Yes, Offer	Is this time paid?	# of Days Allowed	# of Days to Carry Over	Pay Remaining Upon Term?
PTO

Will the Client be offering time off for holidays to the Employees:*

If Yes, how many holidays will be provided each calendar year:

Do you wish to offer Group Benefits to your Employees ? (Full-time EEs Only)

YesNo

Full-time Employees are eligible for health benefits in the US and Employers are required to contribute towards their medical premiums. Please list your contribution amount(s) below for each coverage tier. (NOTE: The minimum amount for 2023 is $362.42 , there is no maximum.)

	Employee Only	Emp + Spouse	Emp + Child(ren)	Family
Monthly Contribution Amount 2023:

1. Do you wish to offer your Employees DENTAL benefits?*

YES - We will offer Voluntary dental benefits (100% EmployEE Paid).YES - We will offer dental benefits with an EmpoyER contribution (% or $ amounts).NO - We are declining to offer this benefit.

1a. Please choose which DENTAL benefit plans you wish to offer your Employees:

	Employee Only	Emp + Spouse	Emp + Child (ren)	Family
Enhanced Elite
Enhanced Premier
Enhanced Standard
Basic Plus
Basic

2. Do you wish to offer your Employees VISION benefits?*

YES - We will offer Voluntary vision benefits ( 100% EmployEE Paid).YES - We will offer vision benefits with an EmployER contribution (% or $ amounts).NO - We are declining to offer this benefit.

2a. Please choose which VISION benefit plans you wish to offer your Employees

	Employee Only	Emp + Spouse	Emp + Child (ren)	Family
VSP Vision Care
Davis Vision

3. Do you wish to offer your Employees Short Term Disability (STD) benefits?*

YES - We will offer Voluntary STD benefits (100% EmployEE Paid).YES - We will offer STD benefits. ( 100% EmployER Paid).NO - We are declining to offer this benefits.

4. Do you wish to offer your Employees Long Term Disability (LTD) benefits?*

YES - We will offer Voluntary LTD benefits (100% EmployEE Paid).YES - We will offer LTD benefits. ( 100% EmployER Paid).NO - We are declining to offer this benefits.

5. Do you wish to offer your LIFE / AD&D benefits?*

YES - We will offer Voluntary LIFE / AD&D benefits (100% EmployEE Paid).YES - We will offer LTD benefits. ( 100% EmployER Paid).NO - We are declining to offer this benefits.

6. Do you wish to offer Guardian's Supplementals benefits - ACCIDENT, HOSPITAL INDEMNITY, and CRITICAL ILLNESS?*

YES - We will offer these benefits as Voluntary (100% EmployEE Paid).NO - We are declining to offer this benefits.

Will this Employee be eligible for a 401(k) / Retirement / Pension Plan?

YesNo

Please send your new employee the following link to complete. Please feel free to click on the link to view the simple form your new hire will complete for our employment purposes.

EMPLOYEE NEW HIRE INFORMATION FORM

Thank you for choosing Lightsource Global for your EOR needs. We appreciate your partnership.

CERTIFICATION & SIGNATURE

The undersigned attests that the information contained in this document is true and correct to the best of the undersigned’s knowledge. The undersigned understands this document is not a contract for service or employment nor will it bind coverage of any kind. This information is strictly governed by HIPAA compliance rules. In the event that information has been intentionally omitted or misrepresented, the employer of record may deny or limit services. I will notify Lightsource Global of any changes to the information imparted here that occur after signing this form.

Signature*

Sign on the line above with your mouse, stylus, or finger if mobile.

Client Implementation Request Form

CLIENT OVERVIEW

LEAVE

PAID HOLIDAYS

MEDICAL BENFITS PLANS

ANCILLARY & SUPPLEMENTAL BENEFIT PLANS

EMPLOYEE NEW HIRE INFORMATION FORM